Presentation on theme: "Telemedicine & e-Health Nicolette de Keizer Dept Medical Informatics University of Amsterdam."— Presentation transcript:
Telemedicine & e-Health Nicolette de Keizer Dept Medical Informatics University of Amsterdam
Evolution of telemedicine 1924: radio doctor 1975 first RCT Comparison of television and telephone for remote medical consultation in NEJM NASA checks vital signs of astronauts 90: introduction of the Internet
Outline Definitions: e-health, telemedicine Quality assurance Laws and ethics Technical possibilities Impact on health care Factors for failure and success Example in Teledermatology
Definition Telemedicine The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities. WHO(2002) Telemedicine is the use of telecommunication technologies to provide healthcare services across geographic, temporal, social, and cultural barriers. J. Reid, 1996
Definitions: e-Health 51 unique definitions (Hans Oh, JMIR, 2005) administration of health data electronically (ESA) e-health is an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies. (Eysenbach, JMIR, 2001) The use of internet technology by the public, health workers, and others to access health and lifestyle information, services and support (Wyatt, JECH, 2002)
Calling names Virtual Outreach Hospitals Without Walls Reaching The Unreached Bridging the Urban-Rural divide
eHealth vs telemedicine eHealth Telemedicine
Quality assurance Code of behaviour Certificate of (trusted) third party
Code of behaviour: e-Health code of Ethics 1.Sincerity: objectives, financial interest 2.Honesty: no misleading information 3.Quality: correct and recent information with acknowledgement 4.Informed consent: use of data 5.Privacy: carefull use of data 6.Professional: professional care 7.Responsible care provision
Laws and Ethics Autorisation – right to read and change information Identification – is person X person X? Laws/Privacy Internet not restricted to country borders Responsibility - Who?
Example NL 20/3/05 I didnt know it would go so fast Disciplines to internet physician Minister surprised about internet development Drug prescription via the internet should be prohibited Agree Neutral Disagree 55% 44% 1% Statement
Example NL (2) College of Hospitals advices Patient and Internet, 20/3/2000 Buying health products via Internet occurs on a limited scale: –5% of interviewees once bought health products via the Internet (most commonly vitamines) –Of the interviewees 71% do not intend to buy in the future.
Entities involved in Telemedicine Telemedicine Platform Desktop PC, Laptop,Palmtop/PDA Telemedicine Software Acquisition,Storage and display Transmission of patient related information Clinical Devices Digital ECG, Electronic Stethoscope, Digital Camera,Tele- pathology Microscope, X-Ray Digitizer Communication Media (mobile) phone, Internet, Bluetooth
Which settings benefits from telemedicine? Only large distance Also small distance
Telemedicine – large distances Developing countries Army Places hard to reach Disasters Space An evaluation of the first year's experience with a low-cost telemedicine link in Bangladesh. Vassallo DJ, Hoque F, Roberts MF, Patterson V, Swinfen P, Swinfen R. Journal of Telemedicine and Telecare, 2001
Telemedicine – small distances Jail Shy, socially challenged people Pressure of work, shortage of personell Nursing homes
Impact on health care Quality of care Access to care Cost of care
Cell-life Impact on health care Quality of care –Diagnostics –Treatment (AIDS patients in South Afrika,Cell-life)Cell-life –Patient satisfaction (early treatment, no live physician)
Outcome measures Quality of Care Diagnostic accuracy Delay in treatment Preventable consultations Adherence to medication Quality of life Mortality and morbidity
Impact on Health Care Access to health care –Patients with communication disabilities (dumb, deaf) –Isolated patients, hard to reach –Independent of time / place –Contact with fellow-sufferers –Education
Outcome measures Access to Care Patients satisfaction Timeliness disease detection Adherence to (treatment) advice
Impact on health care Costs of Health care –Prevention of diseases – lower costs for society –Prevention of consultations Lower costs due to less specialist consultations Higher costs due to more consultations –No valid evidence for cost reduction by telemedicine (Whitten, BMJ, 2002)
Typology of cost studies Types: –Cost analysis - What does the service cost ? –Cost minimization - Does the service save money ? –Cost effectiveness analyse - What is the balance between costs and effects? Perspective: patient, care provider, society?
Other outcome measures Physicians satisfaction Technical aspects: quality of photos, performance of application Usability of the service
Factors of success and failure Success: –Satisfaction patients and health care professionals –Better involved patients –Addition not replacement to physicians practice Failure –Fear of technique –Inaccurate –Limitations in time, money and knowledge
Context High pressure on health care due to: –Shortage on full-time specialists –Aging population Physical joint consultations –33% less referrals (Vierhout et al, Lancet, 1995) Modern information and communication technology more possibilities telemedicine
Teledermatology Telemedicine application in dermatology Dermatology: –High number of GP consultations (ca. 8%) –Visual orientation Teledermatology worldwide and in NL: –Local implementations and financial compensations –No robust scientific evidence for effectiveness and efficiency (o.a. Eminovic et al, BJD 2007)
Conventional care versus teledermatologie GP Dermatologist patiënt patient info Info + images advice patient 35% Conventional care Teledermatology GP Less referals? Less costs?
PERFECT D Primary care Electronic Referrals: Focus on Efficient Consultation using Telemedicine in dermatology Virtual consultations between GPs and dermatologists
PERFECT D methods Multicentre cluster RCT Randomisation GPs –Control group = conventional care / referral –Intervention group = teledermatology All patients go to live dermatologist Cost minimizing study
Less consultations? Live dermatologist Patient referred to dermatologist Control group Intervention group Description signs + digital photos to derm Teleadvice + intervention GP Dermatologist decision: Consultation necessary or unnecessary
Societal perspective Modelling cost components –GP –Dermatologist –Programme costs (camera, software, training, etc.) –Patient –Employer Cost value input: PERFECT D RCT, Handbook, experiment, expert opinion Monte Carlo simulatie (sensitivity & scenario analyse) Less costs?
Cost Benefit Costs + Time GP + investments (camera, website, internet) + training GP + easy to refer Benefits - less consultations to outpatient clinic - less try-outs by GP - Faster treatment in outpatient clinic
Results 605 patients included 312 intervention, 293 control group Preventable consultations: –39% intervention group, 18.3% control group –Most important reason for difference is RECOVERY of patients Costs: –Conventional care: Euro (95%CI, – 461.2) –Teledermatology: Euro (95%CI, – 484.0)
Scenario analysis Unneccesary referals >17%GP TD time <7.5 minutes
Scenario analysis Distance to GP < 55kmDistance to dermatologist
Conclusions Less referals to outpatient clinic but no difference in costs Cost effective when teledermatology is used for specific patient groups or settings: –Higher percentage unneccesary referals –Larger distance to dermatologist –Less time for GP ->integration TD with GP system